Provider Demographics
NPI:1659391571
Name:SAMAYOA, CONRAD (MD)
Entity Type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:
Last Name:SAMAYOA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 W WILSON AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5255
Mailing Address - Country:US
Mailing Address - Phone:773-769-4600
Mailing Address - Fax:773-769-0042
Practice Address - Street 1:1945 W WILSON AVE STE 400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5255
Practice Address - Country:US
Practice Address - Phone:773-769-4600
Practice Address - Fax:773-769-0042
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC44242Medicare ID - Type Unspecified